The normative culture of medicine

The account presented by Hardman and Hutchinson come closes to suggesting that there is no need to further the moral education of those seeking to become medical doctors or other healthcare professionals. Although there might be a need to expand the way in which they understand cultural backgrounds other than their own, and perhaps to better appreciate the role this can play for patients, the idea seems to be that one can rely on the ethical resources already possessed by healthcare professionals and students; as adults (and full members of the broader moral community) they are already fully fledged and culturally situated moral agents.

Hardman and Hutchinson do not, however, seem to fully appreciate the fact that medicine and healthcare is its own (sub)culture and, as such, it has its own moral order. Indeed, the normative structure or ethos of a particular culture is particularly significant such that it makes a substantial contribution to its definition. As a result, membership of a particular culture—which is to say possession of the requisite dispositions or the ubiquitous expertise required to negotiate a particular moral order3 4 —commonly requires individuals to internalise a range of largely implicit values, norms and principles. That this is the case is clear from research that takes professional reproduction as its focus where we commonly find fairly extensive discussion of medical student’s (moral) socialisation.5–8 Such work suggests that the process of medical education and training entails transitioning neophytes from the periphery to the core of medical culture.

Thus, when Hardman and Hutchinson suggest that ‘cultivating a greater understanding of and sensitivity towards their patients’ everyday lives’1 should be central to medical education, they are advocating for the development of a moral culture or ethos that implicitly recognises and values the significance of patient’s perspectives. Of course, it would be difficult to find a modern medical school that does not seek to cultivate such sensitivities, at least to some degree. Such ideas are central to discourses of professionalism as well as notions of cultural competency and it is therefore the case that something of the required ethos already exists within the culture of medicine. Furthermore, it is arguably the case that the emergence and development of this ethos is itself tied to the ‘special principles’ that supposedly ‘estrange clinicians from everyday human concerns’.1

The fact is that philosophical medical ethics and bioethics more generally has played a central role in shifting the ethos of medicine away from paternalism and towards one in which respect for patient autonomy is central. As such, respect for autonomy is not simply a formal ethical principle of medical practice but something that has been assimilated into the moral culture of medicine. The result is that patient autonomy has become a key part of the ethos of contemporary healthcare.9 The practice of ethical medicine requires more than ordinary moral development and ‘specialised biological knowledge’.1 Not only must those who seek to become medical professionals come to inhabit the moral culture of healthcare, they must also develop certain reflective and analytic abilities characteristic of modern, which is to say philosophical, medical ethics, or so I suggest in the following section.

The need for philosophical medical ethics

The ethos of particular cultures and social fields—their values, norms and principles—provides a moral order or structure to the practices situated within them.ⁱⁱ However, three points are worth making. First, simply acting in accordance with the implicit norms of a particular culture does not and cannot amount to the sum total of ‘ethics’ or ‘ethical action.’ Any account of moral agency must include the exercise of reason within its scope. Second, it is erroneous to dichotomise culture and reason. Medicine is a reflective practice and the ability to address oneself to the ethical concerns that arise in the clinical context is an important feature of this practice. Third, modern society is not homogenous and not only is it the case that it is constituted by a variety of social fields and associated (sub)cultures, but these fields and subcultures can and do overlap and relate to one another. Both medicine and philosophical medical ethics or (academic) bioethics can be seen in these terms. Indeed, this point has already been established via the suggestion that, having become an established field of enquiry, bioethics and its mainstay philosophical medical ethics have made a significant contribution to the reformation of medical morality.

In this context, one can consider the formal ethics education of medical students as a process of ethical enculturation, something that is intertwined with, but distinct from, their moral socialisation.7 8 While the analogy is imperfect, one does not learn to play tennis or ride a bike by simply practising; verbal instruction and coaching are essential to the development of the required skills.10 As a reflective practice, formal ethics education can play such a role in the moral transformation of healthcare students into professionals. Equally, considering the way in which it is pursued by philosophers and bioethicists, it is clear that reasoning about ethics is its own activity; it is a practice, one that can be done with more or less skill or expertise.4 While healthcare professionals may not approach such practices in the same way as expert bioethicists, and arguable do so in accordance with their own (ethno)methodologies,11 it is important to properly recognise the relationship between the pursuit of ethics in the clinic, in professional domains more generally and in the academy.

Thus, while there is good reason to debate the role of philosophical moral theories in the ethics education of healthcare professionals,12 the idea that there is no need for them to reflect on ‘ethics’ and ‘values’ as general and theoretical words, or that ‘prior knowledge of philosophical ethics’ serves no purpose, should be rejected outright.1 Indeed, the idea that ‘an ethical situation is grounded in particular, everyday concerns, which are often resolved in a shared and negotiated cultural background’1 would seem to miss much of what is significant about many of the issues that can arise in healthcare and are discussed in the medical ethics literature. It also fails to recognise the relevance of professional governance, ethical guidelines and health law for practice and the significance that formal discussion of and reflection on the problems encountered by healthcare professionals has for the formation and reformation of such regulatory structures.

By way of illustration, one might take the example of Jim (as outlined by Hardman and Hutchinson) and compare it to a recent case that occurred in the UK, and which came to light via subsequent legal proceedings.iii Jim has been diagnosed with Autosomal dominant polycystic kidney disease and is debating whether or not he should inform his children. The UK case similarly involved a father (‘F’) being diagnosed with a genetic condition and his decision to tell his children. One could argue that both Jim and F wish to ‘shield [their] daughters from harm and discomfort’.1 However, while it is perhaps justifiable for Jim to withhold information or delay its provision, it is questionable if F should have been permitted to do the same. As it turns out, F‘s motivation for not telling his daughter was that she happened to be pregnant. F wanted to withhold his diagnosis in order to preempt the possiblity that she might seek a termination. The question is, of course, how those involved in Fs care should respond; if they owe a duty of care to the daughter and what it might mean if they do.

It is naive to suppose that such issues are merely ‘everyday concerns’ which can be ‘resolved in a shared and negotiated cultural background’.1 Many of the ethical issues encountered by healthcare professionals are not matters that can be resolved by better understanding the perspective of their patients or simply by engaging with them from within a shared cultural horizon. The duty of care owed by healthcare professionals can often be a complex matter and value-laden conflicts between patients and healthcare professionals are not necessarily resolvable. Not only is it the case that some ethical issues, such as whether or not to provide confidential information to other interested parties against the wishes of the patient, belong to the medical and healthcare professionals but they should also be subject to broader consideration, debate and analysis by both experts and the broader public. Indeed, in at least some cases, such issues should be subject to regulatory frameworks and legal judgment.